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After months of fear, uncertainty and doubt, the Obama administration holds the high ground. When the U.S. Supreme Court upheld the Patient Protection and Affordable Care Act (now more than ever deserving the nickname Obamacare), it erected a defensible position behind which the government can change the health-insurance system and health care in America.

The court also set the battleground for the next two or three elections: Republicans cannot effectively repeal the health-care law without winning the presidency, holding the House of Representatives and turning 13 Senate seats from "D" to "R" to achieve a filibuster-proof, 60-vote majority. Mandates of that sort are rare, and almost impossible to achieve in one election.

Some enemies of Obamacare believe that a majority of the people are as angry as they are; certainly the angry people no longer have a reason to hold back. Surely it will be easier for Mitt Romney and Republican congressional candidates to run against Obamacare than to present their alternative to fill a void left by the Supreme Court.

Even if the country continues its swing against Obamacare for two or three election cycles, it is still doubtful whether its fundamental points will be repealed, and even more unlikely that free markets in insurance will ever be restored.

Change Is Not Easy

If they win this year, the Republicans will not be powerless; in Washington monkey wrenches grow on trees so they can be thrown into the governmental machinery. Key parts of Obamacare were enacted through legislative budget rules, which don't require 60 votes, so a narrow Republican majority in the Senate might be able to repeal them the same way. They include:

• The penalty tax for violating the individual mandate to purchase health insurance.

• The Independent Payment Advisory Board and its broad power to rein in the cost of Medicare by reducing benefits.

• Additional Medicare benefits for prescription drugs.

A Republican administration also could write rules for Obamacare that would make it less expensive and less effective. But the basic points of the law would remain in effect, especially essential benefits, guaranteed issue, community rating and abolition of annual and lifetime insurance limits.

Essential benefits are whatever the Department of Health and Human Services says they are. Guaranteed issue means that insurance companies must accept all applicants no matter how sick they are. Community rating means that insurance companies must apply one rate for all residents of a territory, regardless of their health, gender, age or other risk factors. Ending limits means that health insurance will become an open-ended benefit by 2014.

Thus Obamacare brings us closer to the end of health insurance as a private contract between independent parties. It advances the transformation of insurance into welfare, although it obfuscates the costs and the sources of the funds to pay for them.

Target for Sloganeering

With the slogan "Repeal and Replace," Romney will make Obamacare the focal point of his campaign. "If we want to get rid of Obamacare, we have to replace President Obama," he said in his speech a couple of hours after the Supreme Court issued its ruling. But Romney also made it clear again that he accepts the intent of Obamacare.

He assured the country that he favors guaranteed access to affordable health care, a federal guarantee that people will not lose insurance coverage, and in general, government efforts to lower the cost of health care and health insurance.

Most Americans probably agree, which means that Romneycare would look a lot like Obamacare, with different details. Fundamental reform of health care will have to wait for fundamental change in the aspirations and fears of the American people. Will they accept that cheaper, more widely available health insurance almost certainly will drive up the cost of health care? Will they recognize that even in America, really good health care is a luxury, not a human right?

Cheap government health care (imagine Army field hospitals administered by the IRS) could be a sensible choice for Americans who understand the trade-off between price and quality. And a system of free-market health insurance and private hospitals without price controls and no last-minute rescues for those who didn't pay would also be sensible. But neither is very attractive.

In the first case, Americans want everyone to have the best health care money can buy, especially if someone else's tax money pays for it. In the second case, Americans don't want to see hospitals throwing uninsured patients into the street to die, especially if someone else's money pays for indigent care.

Effective Combination

One answer is to combine the systems to create two tiers of cost with two tiers of quality. If the government provides for charity care, it might be diligent and parsimonious about the care it provides, offering long lines, impersonal care, cramped quarters, and limited access to expensive drugs and procedures along with the low price tag.

Government care should not be an attractive alternative to private care and private insurance, but it could be an alternative of last resort, as Medicaid is for the poor. A two-tier system could include a limited version of Medicaid, available to all who want to buy cheap health insurance with essential benefits, guaranteed issue, community rating and no annual or lifetime insurance limits.

The rest of us would subsidize the new Medicaid with a dedicated new tax on top of our premiums, so that those who pay the bills would know the cost of mandated charity.

Such a system wouldn't be as cheap or as pretty as we might wish, but it would be fairer and more effective at covering all Americans without bankrupting the country or its health-care providers.